COLUMBIA COUNTY SHERIFF S DEPARTMENT ELECTRONIC MONITORING PROGRAM RULES/REGULATIONS

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "COLUMBIA COUNTY SHERIFF S DEPARTMENT ELECTRONIC MONITORING PROGRAM RULES/REGULATIONS"

Transcription

1 COLUMBIA COUNTY SHERIFF S DEPARTMENT RULES/REGULATIONS Inmate Name: File Number: 1. You are responsible for all of the applicable rules as established for the Columbia County Huber Facility as well as specific rules for the Electronic Monitoring Program. You will follow all established home, work, etc rules. Unauthorized deviation from your schedule and/or approved travel routes is a violation. 2. You shall comply with all verbal and written instructions from the Jail Staff. 3. You shall remain at your approved residence at all times unless you have specific Security Staff authorization to leave. 4. You shall have a permanent residence in Columbia County unless otherwise approved. 5. You shall avoid any conduct that is a violation of any law, municipal, or county ordinance. You may not associate with any criminals, substance abusers, or gang members. 6. You shall not change residence, employment, or phone number without permission from a Jail Supervisor. 7. You shall have your telephone operational at all times with no additional services (3-way calling, caller ID, call forwarding, or answering machine) that have not been approved by a Jail Supervisor. 8. You shall report as directed for scheduled and unscheduled appointments. 9. You shall not have alcohol in your residence or on your property, or use (consume, ingest, or take into my body) and drugs (legal or illegal) or alcohol that has not been prescribed by a physician. This includes all over the counter nonprescription medication and mouthwashes, which contain alcohol. You will be required to submit to scheduled and random chemical testing and/or urinalysis, at your expense. 10. You will not enter the premises of any bar or tavern. 11. Any Police contacts must be reported immediately to Jail Staff for forwarding to a Jail Supervisor. 12. You shall be subject to random home checks. You will allow anyone who comes to your home on behalf of the Sheriff s Department, permission to enter your home, to verify your compliance with program rules and conditions, and condition of program equipment. 13. Your schedule must be approved by a Jail Supervisor. Any changes in your schedule need prior approval 24 hours in advance. 14. You are responsible for informing any one at your residence about the program rules. NO extended or conjugal visits allowed. Only persons listed as a permanent resident on your initial application may stay overnight at your residence. 15. Initially, you will pay for two weeks in advance to initiate the program. You will then pay in advance the weekly fee, which is charged, for participation in the Electronic Monitoring Program. You will report to the Columbia County Jail once a week at scheduled times to make your fee payment and submit a work and appointment schedule. Your schedule must be for one week in advance. Your fees will be paid in cash or money orders. Personal checks will not be accepted. You will pay $ per week to offset the cost of the program and a $30.00 initial set-up fee. Failure to make payments as scheduled will result in your return to the Columbia County Jail. 16. You shall be held responsible for any damage to the equipment. You shall not tamper with, attempt, or allow anyone else to tamper with or attempt to fix the equipment. All equipment shall be returned to the Columbia County Jail at 403 Jackson St, Portage, WI (608) , upon termination of the program. If you do not bring the equipment back in good condition, the District Attorney can charge you with theft or vandalism. Page 1 of 2

2 17. You shall insure that your telephone and electricity expenses are paid for on time, disconnection is a violation. If your phone or electricity fail for any reason, you will report it immediately to the Columbia County Jail. 18. You may only disconnect or move the program equipment upon specific instruction from the Jail Staff. 19. You will place the Tracking Device in the Docking Station for a minimum of (10) ten hours per day and at all times while at home. 20. You will place the Tracking Device in its Docking Station immediately upon returning home. You will not remove the Tracking Device from the Station until you are authorized to leave the house for work. 21. You understand that all movement will be tracked and stored as an official record. 22. You will not enter areas that are defined as off-limits. 23. You agree to respond immediately to all messages that are sent to the MTD. 24. You are not allowed to submerge the bracelet into water. You are allowed to take a shower with the bracelet. 25. Other specific rules may be imposed at any time. It has been explained to you that any violation, while participating in the Columbia County Electronic Monitoring Program, may result in your immediate return to the jail. Your failure on this program may also result in the loss of Good Time and/or Huber privileges upon return to Jail. If you fail on this program, you will serve your remaining sentence at the Huber Center or the Jail. I agree that the County of Columbia, the Columbia County Sheriff s Department and its agents, are not liable for any damages incurred as a result of my participation in the program. I understand and do agree to abide by all of the conditions of this informed consent. Participant s Signature Date Signed Officer Signature Date Signed Elec Mont Rules.doc Page 2 of 2

3 COLUMBIA COUNTY SHERIFF S DEPARTMENT APPLICATION FOR ELECTRONIC MONITORING Applicant Name First MI Last Date of Birth File Number Social Security # Address How Long Lived At This Address City County Zip Code Telephone Number / Telephone Company / Sex Race Height Weight Eye Color Hair Color Scars/Marks/Tattoos Marital Status (Circle One) Married / Single / Divorced Do you rent or own? (Circle One) Rent / Own List ALL People Living With You: A. B. C. D. E. NAME AGE RELATIONSHIP Are you on Probation? YES / NO If yes, your Agent s Name What is the current charge(s) you are in Jail for? What is the length of your sentence? What is your scheduled begin date? Release date? Do you have any charges pending (List Charges)? Have you ever been convicted of a domestic charge? (Circle One) YES / NO If so, when? Victim Name Do you have any restraining orders or injunctions? Do you have special family circumstances we should know about? How is your health at this time? Are there weapons in your home? (Circle One) YES / NO If yes, location and type of weapons:

4 Do you have any disabilities or special medical conditions? Are you currently taking any prescribed medication(s)? (Circle One) YES / NO If yes, name of MEDICATION(S) Name of Doctor Phone # Have you ever been treated for drug or alcohol abuse? (Circle One) YES / NO If yes, location and reason for treatment Do you have regularly scheduled appointments besides work (i.e..treatment, counseling)? In the space provided give a short explanation as to why you should be eligible for this program: EMPLOYMENT INFORMATION Employer Address City County Phone # Type of Work Supervisor Name Phone # Weekly Work Hours (Days/Time) Length of Employment Does your job location vary? (Circle One) YES / NO Does your supervisor work on site with you? (Circle One) YES / NO Does your job take you out of the county? (Circle One) YES / NO Are you self employed (proof required)? (Circle One) YES / NO Will you have transportation that meets Huber requirement (i.e., valid DL, vehicle registration, etc.)? (Circle One) YES / NO Explain your transportation and how it meets Huber requirements: Applicant: ACCEPTED / DENIED Date: Reviewing Officer Signature:

5 COLUMBIA COUNTY SHERIFF S DEPARTMENT INMATE CONTRACT This contract constitutes the agreement made between the inmate and the Columbia County Jail for their role in the Electronic Monitoring Program. The undersigned inmate acknowledges a complete understanding of the rules and regulations of the Electronic Monitoring Program, and agrees to live within these rules and regulations. The inmate also pledges that all information given to the monitoring staff during the application and classification process is true to the best of their knowledge. The rules of the Electronic Monitoring Program have been provided to me. I fully understand what is expected of me and the possible consequences of my failure to comply with these rules. I agree to release the Columbia County Sheriff s Department, its personnel, and the vendor from any liability associated with my participation in the Electronic Monitoring Program. I understand that upon completion of the program, the equipment will be returned to the Columbia County Jail. I also must complete normal release from custody procedures at the Columbia County Jail on my release date. I am not allowed to remove my ankle strap at anytime. Jail Staff will remove the bracelet upon my release. My signature confirms the above as well as my receipt of the Electronic Monitoring Program equipment. INMATE NAME SIGNATURE DATE OFFICER SIGNATURE DATE

6 COLUMIBA COUNTY SHERIFF S DEPARTMENT Dennis Richards, Sheriff 711 E. Cook Street Portage, WI Office (608) Fax (608) EMPLOYER AGREEMENT will be participating in the Columbia County Jail Electronic Monitoring Program. The inmate will be enrolled in the program starting and ending. A requirement of this program is that the employer notify the Columbia County Huber Officer at (608) if the employee fails to report for work or leaves work during his/her assigned shift. The person on EMP may work up to six days a week. The responsibility for notification of shift changes or overtime rest with the employee who is on EMP and verified by the employer. The employee is required to contact the Jail Supervisor with schedule changes at least 24 hours in advance, and they are only allowed one schedule change per week. I agree to notify the Columbia County Jail/Huber Center of any violation. SUPERVISOR SIGNATURE Date COMPANY PHONE

This is very important for work release, self-employment, and childcare release.

This is very important for work release, self-employment, and childcare release. Please review this packet. It contains information that you will need to know about serving your jail sentence. Once you have completed reviewing the information, call the Huber Sgt. to schedule an appointment

More information

THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO.

THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO. THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO. 1 P.O. Box 416 - Manchester, MD 21102 Fire Calls: 911 Meeting Night: First Tuesday of each month Membership Fee: $5.00 / Year Date Application for

More information

Within this application package you will find the following forms and information:

Within this application package you will find the following forms and information: Mechanicsville Volunteer Fire Department, Inc. Post Office Box 37 Mechanicsville, MD 20659-0037 Non Emergency: (301) 884-4709 / Emergency: Dial 9-1-1 www.mvfd.com Dear Membership Applicant: On behalf of

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION Thank you for your interest in Estes Park Medical Center. The mission of the Estes Park Medical Center is to make a positive difference in the health and wellbeing of all we serve. VOLUNTEER APPLICATION

More information

ELLICOTT CITY VOLUNTEER FIREMEN S ASSOCIATION, INC.

ELLICOTT CITY VOLUNTEER FIREMEN S ASSOCIATION, INC. ELLICOTT CITY VOLUNTEER FIREMEN S ASSOCIATION, INC. APPLICATION FOR PROBATIONARY MEMBERSHIP Emergency ID# (assigned by LOSAP committee) (enter your 4 digit number if assigned one previously by Howard County)

More information

Plymouth County Sheriff s Department. Application and Personal History Statement. Application. Please Print Clearly

Plymouth County Sheriff s Department. Application and Personal History Statement. Application. Please Print Clearly Plymouth County Sheriff s Department Application and Personal History Statement Position applied for: Salary sought: Personal Application Please Print Clearly Date: Last: First: Middle: List your current

More information

C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application

C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application Please Print Any incorrect, incomplete, false or misleading information on this application will void

More information

BASIC REQUIREMENTS LAW ENFORCEMENT EXPLORER PROGRAM. Minimum 2.0 academic grade point average prior to and maintained after appointment.

BASIC REQUIREMENTS LAW ENFORCEMENT EXPLORER PROGRAM. Minimum 2.0 academic grade point average prior to and maintained after appointment. BASIC REQUIREMENTS LAW ENFORCEMENT EXPLORER PROGRAM AGE: EDUCATION: PHYSICAL FITNESS: UNITED STATES CITIZENSHIP: Explorer / Cadet - Minimum Age 14 (Completed 8 th grade), or 15 years of age and not yet

More information

State of North Carolina Department of Correction Division of Prisons

State of North Carolina Department of Correction Division of Prisons State of North Carolina Department of Correction Division of Prisons POLICY & PROCEDURES Chapter: F Section:.0400 Title: Emergency Leave Issue Date: 10/03/05 Supersedes: 08/26/02.0401 General This policy

More information

Present Address Telephone ( ) Street City State Zip. Permanent Address Telephone ( ) Social Security Number / / address

Present Address Telephone ( ) Street City State Zip. Permanent Address Telephone ( ) Social Security Number / /  address Application for Classified Personnel Minden Public Schools An Equal Opportunity/Affirmative Action Employer 543 West Third Phone: (308) 832-2440 Minden, NE 68959 Fax: (308) 832-2567 Please type or print

More information

A Nine to Eighteen Month Residential Aftercare Program

A Nine to Eighteen Month Residential Aftercare Program APPLICATION Please Choose One: St. Louis Guest Homes Fort Good Shepherd Ranch Access to Recovery II referral: Yes No Please answer all questions honestly and completely. GENERAL INFORMATION Last Name First

More information

Macon County Mental Health Court. Participant Handbook & Participation Agreement

Macon County Mental Health Court. Participant Handbook & Participation Agreement Macon County Mental Health Court Participant Handbook & Participation Agreement 1 Table of Contents Introduction...3 Program Description.3 Assessment and Enrollment Process....4 Confidentiality..4 Team

More information

Lompoc Police Department Explorer Post #700

Lompoc Police Department Explorer Post #700 Lompoc Police Department Explorer Post #700 APPPPLIICATIION FOR MEMBERSSHIIPP Print legibly all information required and answer all questions as completely and truthfully as possible. After filling out

More information

CITY OF GLENDALE APPLICATION FOR POLICE OFFICER CHECK LIST

CITY OF GLENDALE APPLICATION FOR POLICE OFFICER CHECK LIST CITY OF GLENDALE APPLICATION FOR POLICE OFFICER CHECK LIST Be a U.S. Citizen. To apply you must: Have never been convicted of a felony (unless pardoned) Ability to lawfully possess a firearm Prior to appointment

More information

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE: *Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE

More information

EMPLOYMENT PROCEDURES FOR PARAPROFESSIONAL STAFF

EMPLOYMENT PROCEDURES FOR PARAPROFESSIONAL STAFF EMPLOYMENT PROCEDURES FOR PARAPROFESSIONAL STAFF PHASE I 1. Secure application form in person, mail, telephone, or website (www.pittsville.k12.wi.us). 2. Return the completed application form with a copy

More information

East Baton Rouge Parish Junior Deputy

East Baton Rouge Parish Junior Deputy East Baton Rouge Parish Junior Deputy 2018 Application Packet Sheriff Sid J. Gautreaux, III Captain Randy M. Aguillard Program Director raguillard@ebrso.org Junior Deputy Membership Rules All members of

More information

Mental. Health. Court. Handbook

Mental. Health. Court. Handbook Mental Health Court Handbook Introduction/Eligibility The 8 th Circuit Court Mental Health Court is for people who have been convicted of a crime and have mental health issues suggesting a need for comprehensive

More information

Gilmer Independent School District 500 So. Trinity Gilmer, Texas Phone: (903) FAX: (903)

Gilmer Independent School District 500 So. Trinity Gilmer, Texas Phone: (903) FAX: (903) Gilmer Independent School District 500 So. Trinity Gilmer, Texas 75644 Phone: (903) 841-7400 FAX: (903) 843-5279 Employment Application for Professional Personnel POSITION (S) FOR WHICH YOU ARE APPLYING:

More information

Polk County Sheriff s Office

Polk County Sheriff s Office Polk County Sheriff s Office Explorer Post 900 Application Grady Judd, Sheriff Polk County Sheriff s Office 1891 Jim Keene Blvd Winter Haven, FL 33880 (863) 298-6200 www.polksheriff.org Pride In Service

More information

COUNTY OF SACRAMENTO Probation Department 3201 FLORIN-PERKINS ROAD, SACRAMENTO, CALIFORNIA TELEPHONE (916) FAX (916)

COUNTY OF SACRAMENTO Probation Department 3201 FLORIN-PERKINS ROAD, SACRAMENTO, CALIFORNIA TELEPHONE (916) FAX (916) RULES AND REGULATIONS The Ride-Along Program offers members of the public the opportunity to interact with officers from our Department. The program seeks to increase public awareness regarding the functions

More information

GLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER

GLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER 100 Sulphur Springs Road Brunswick, GA 31520 Telephone: (912) 554-7600 Web Page Address: www.glynncountysheriff.org INSTRUCTIONS AND INFORMATION PLEASE READ CAREFULLY BEFORE BEGINNING 1. Please complete

More information

SACRAMENTO COUNTY SHERIFF S DEPARTMENT SCOTT R. JONES Sheriff. Volunteer Packet

SACRAMENTO COUNTY SHERIFF S DEPARTMENT SCOTT R. JONES Sheriff. Volunteer Packet SCOTT R. JONES Sheriff Volunteer Packet VIPS (Volunteers In Partnership with the Sheriff) DART (Dive And Rescue Team) SAR (Search And Rescue) SHARP (Sheriff s Amateur Ham Radio Program) Sacramento Sheriff

More information

Volunteer Application

Volunteer Application Volunteer Application Thank you for your generosity. The time and energy of our volunteers make Women and Children s Horizons effective for survivors and victims of sexual and domestic abuse. Please complete

More information

2016 Multi-Jurisdictional Law Enforcement Explorer Academy

2016 Multi-Jurisdictional Law Enforcement Explorer Academy 2016 Multi-Jurisdictional Law Enforcement Explorer Academy All questions must be answered. If something does not apply please indicate N/A. Note: If there are any un-answered questions on this application

More information

Indiana Energy Assistance Program Application Part 1. Personal Information

Indiana Energy Assistance Program Application Part 1. Personal Information INSERT AGENCY LOGO 2017-2018 Indiana Energy Assistance Program Application Part 1. Personal Information Your Name Date of Birth First MI Last Social Security Number MM-DD-YYYY Current Home Address: Street

More information

HAMILTON COUNTY SHERIFF S OFFICE SPECIAL DEPUTY APPLICATION

HAMILTON COUNTY SHERIFF S OFFICE SPECIAL DEPUTY APPLICATION HAMILTON COUNTY SHERIFF S OFFICE SPECIAL DEPUTY APPLICATION The classification of Special Deputy is a voluntary, non-compensated position affiliated with the Sheriff s Office and requires the individual

More information

Initials of State and Out of State DL # Complete as Applicable

Initials of State and Out of State DL # Complete as Applicable Bridgeway Center Inc. Community & Court Education Services Enrollment Form Have you ever attended any classes at Bridgeway Center, Inc.? Yes No Today s Date First Name Middle Name Last Name / / Address

More information

UMATILLA COUNTY EMPLOYMENT APPLICATION

UMATILLA COUNTY EMPLOYMENT APPLICATION DATE/TIME APPLICATION RECEIVED: BY: UMATILLA COUNTY EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER REVISED 01/17 Human Resources Department Umatilla County Courthouse 216 SE 4 th Street, Pendleton,

More information

YOUTH FOR TOMORROW NEW LIFE CENTER

YOUTH FOR TOMORROW NEW LIFE CENTER APPLICATION N YOUTH FOR TOMORROW NEW LIFE CENTER CHRISTIAN ACADEMCY AND THERAPEUTIC BOARDING SCHOOL 2016-2017 Revised 7/1/2016 Child s Name: Step 1 Application Process Date Once we receive all of the information

More information

Filer Police Department 300 Main Street Office: P.O. Box 140 Dispatch: Filer, Idaho Fax:

Filer Police Department 300 Main Street Office: P.O. Box 140 Dispatch: Filer, Idaho Fax: Filer Police Department 300 Main Street Office: 208 326-4123 P.O. Box 140 Dispatch: 208 735-1911 Filer, Idaho 83328 Fax: 208 326-5004 www.cityoffiler.com 911 Emergency EQUAL OPPORTUNITY EMPLOYER Prospective

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care

More information

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT

More information

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission: Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment

More information

RESERVE DEPUTY SHERIFF APPLICATION WHAT IS A RESERVE DEPUTY SHERIFF?

RESERVE DEPUTY SHERIFF APPLICATION WHAT IS A RESERVE DEPUTY SHERIFF? RESERVE DEPUTY SHERIFF APPLICATION Qualifications to Join the Oklahoma County Reserve Deputy Program include: Be a U.S. Citizen; Be at least 21 years of age at the time of appointment; Be a high school

More information

City of Pigeon Forge Police Department. Position: The City of Pigeon Forge Police Department is accepting applications for Communications Officer.

City of Pigeon Forge Police Department. Position: The City of Pigeon Forge Police Department is accepting applications for Communications Officer. City of Pigeon Forge Police Department Position: The City of Pigeon Forge Police Department is accepting applications for Communications Officer. Qualifications: Must be at least eighteen years of age

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals

More information

REFERENCES: (If applying to assist with religious activities, please include a member of the clergy as a reference.)

REFERENCES: (If applying to assist with religious activities, please include a member of the clergy as a reference.) BRRJA APPLICATION FOR VOLUNTEER SERVICES SITE: AA NA Academic Religious Other DATE: FULL NAME: Last First Middle HOME ADDRESS: Street City State Zip PHONE: Home Cell Work EMAIL ADDRESS: EDUCATION: HS Degree

More information

Last Name First Middle Initial Maiden Name (if applicable)

Last Name First Middle Initial Maiden Name (if applicable) Application For Sheriff Deputy Employment PLEASE PRINT IN INK OR TYPE Marinette County Human Resources 1926 Hall Avenue Marinette, WI 54143-1717 Marinette County is an equal opportunity employer. All hiring,

More information

Employment Application NOTICE OF POLICY

Employment Application NOTICE OF POLICY Shayne E. Heap, Sheriff Elbert County Sheriff s Office 751 Ute Avenue, P.O. Box 486 Kiowa, Colorado 80117 Ph: 303-621-2027 Fax: 303-621-2055 www.elbertcountysheriff.com Employment Application NOTICE OF

More information

TRAVIS COUNTY EMERGENCY SERVICES DISTRICT #4 FIRE AND EMT ACADEMY CADET CLASS XV APPLICATION

TRAVIS COUNTY EMERGENCY SERVICES DISTRICT #4 FIRE AND EMT ACADEMY CADET CLASS XV APPLICATION TRAVIS COUNTY EMERGENCY SERVICES DISTRICT #4 FIRE AND EMT ACADEMY CADET CLASS XV APPLICATION 11800 North Lamar #4B Austin, Texas 78753 (512) 836-7566 Office Hours 8:00am - 4:00pm READ ALL OF THE MINIMUM

More information

Albuquerque Police Department Applicant Additional Documents. Name: Page 1 of 9

Albuquerque Police Department Applicant Additional Documents. Name: Page 1 of 9 Albuquerque Police Department Applicant Additional Documents Name: Page 1 of 9 Additional Documents Needed Instructions You will need to locate/gather all of the following documents and bring them with

More information

Washington County Tennessee Sheriff s Office. Ed Graybeal, Sheriff. Employment Application Packet

Washington County Tennessee Sheriff s Office. Ed Graybeal, Sheriff. Employment Application Packet Washington County Tennessee Sheriff s Office Ed Graybeal, Sheriff Employment Application Packet PLEASE READ CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY. INCLUDE A COPY OF YOUR DRIVER S LICENSE, BIRTH

More information

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM. I,, have received a copy of Dr. Andy Hand s Notice of Privacy Practice.

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM. I,, have received a copy of Dr. Andy Hand s Notice of Privacy Practice. Central Texas Institute Of Plastic Surgery, PA Dr. Andy Hand, M.D. Plastic and Reconstructive Surgery Cosmetic Plastic Surgery RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I,, have

More information

1. NAME: 2. SOCIAL SECURITY NO.: Last First Middle (As it appears on your Social Security Card)

1. NAME: 2. SOCIAL SECURITY NO.: Last First Middle (As it appears on your Social Security Card) U 2BTEXAS DEPARTMENT OF CRIMINAL JUSTICE 0BUEMPLOYMENT APPLICATION SUPPLEMENT U UPlease check those that apply U New Applicant Former Employee Veteran s Reinstatement ERS Retiree INSTRUCTIONS: All questions

More information

Please note: Assistance filling out the FAFSA is available. Please ask for more information.

Please note: Assistance filling out the FAFSA is available. Please ask for more information. HOUSING College Housing Assistance Program Application THA Form (#) REM-CHP-01 You must be an enrolled T.C.C. student registered for or attending classes to participate in this program. Please complete

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I

More information

YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT

YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT *This information will be used for verification and identification purposes only

More information

Calhoun County Sheriff s Office. Sheriff Thomas Summers Jr. Employment Application

Calhoun County Sheriff s Office. Sheriff Thomas Summers Jr. Employment Application Name: Calhoun County Sheriff s Office Sheriff Thomas Summers Jr. Employment Application Equal Opportunity Employer 2811 Old Belleville Road (PO Box 749) St. Matthews, SC 29135 803-874-2741 www.calhounscsheriff.com

More information

Credentialing Application

Credentialing Application Credentialing Application 1. NAME Last First MI Degree Gender 2. BIRTH, SOCIAL SECURITY & E-MAIL ADDRESS Date of Birth Social Security # E-Mail Address 3. PRACTICE, OFFICE & SPECIALTY INFORMATION 3.1 Please

More information

Sign and return included forms. (Background Check Form, Authorization to Release Information Form, and Vehicle Use Agreement)

Sign and return included forms. (Background Check Form, Authorization to Release Information Form, and Vehicle Use Agreement) To: Employees with Conditional Offers of Employment Re: Background Checks All offers of employment or participation in any activity involving minors in a University sponsored program with The University

More information

APPLICATION FOR CERTIFICATION

APPLICATION FOR CERTIFICATION APPLICATION FOR CERTIFICATION SEX OFFENDER TREATMENT PROVIDER ASSOCIATE PROVIDER LEVEL California 1515 S Street, 212- North, Sacramento, CA 95811 Website: www.casomb.org Contact Information for Inquiries

More information

Hamburg Township Police Department MERRILL HAMBURG, MICHIGAN 48139

Hamburg Township Police Department MERRILL HAMBURG, MICHIGAN 48139 Hamburg Township Police Department 10409 MERRILL HAMBURG, MICHIGAN 48139 RICHARD DUFFANY, CHIEF OF POLICE PHONE: (810) 231-9391 FAX: (810) 231-9401 POSITION: Police Officer (Full Time) Hamburg Township

More information

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY

1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY 2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group

More information

MONTGOMERY COUNTY POLICY AND PROCEDURE MANUAL

MONTGOMERY COUNTY POLICY AND PROCEDURE MANUAL MONTGOMERY COUNTY BEHAVIORAL HEALTH COURT POLICY AND PROCEDURE MANUAL ESTABLISHED JUNE 2009 TABLE OF CONTENTS Introduction and Mission................................. 1 Eligibility and Competency................................

More information

Town of Southampton Police Department

Town of Southampton Police Department Town of Southampton Police Department David G. Silvernail Police Chief Business 413-527-1120 Fax 413-527-8776 PO Box 239, 8 East Street, Southampton, Ma 01073 Police Officer Application Applications are

More information

SUMMER INTENSIVE RESIDENT ASSISTANT APPLICATION PACKET

SUMMER INTENSIVE RESIDENT ASSISTANT APPLICATION PACKET SUMMER INTENSIVE RESIDENT ASSISTANT APPLICATION PACKET Dear Applicant, Thank you for your interest in the Milwaukee Ballet Summer Intensive Resident Assistant Position. Resumes will be collected until

More information

EMPLOYMENT PROCEDURES FOR SUBSTITUTE TEACHING STAFF

EMPLOYMENT PROCEDURES FOR SUBSTITUTE TEACHING STAFF EMPLOYMENT PROCEDURES FOR SUBSTITUTE TEACHING STAFF PHASE I 1. Secure application form in person, mail, telephone, or website (www.pittsville.k12.wi.us). 2. Return the completed application form with a

More information

Marshall County Community Corrections

Marshall County Community Corrections Marshall County Community Corrections General Rules and Special Conditions 501 N. Center St. Suite 100 Plymouth, IN 46563 574-935-8782 www.co.marshall.in.us Name (Print Name) 1 Pre-Intake Instructions

More information

Eau Claire County Mental Health Court. Presentation December 15, 2011

Eau Claire County Mental Health Court. Presentation December 15, 2011 Eau Claire County Mental Health Court Presentation December 15, 2011 Collaboration State & County Government Eau Claire County Mental Health & Jail Diversion Task Force First Brought State & County Agencies

More information

PUBLIC SERVICE COMMISSION FOR-HIRE DRIVER S LICENSE APPLICATION CHECKLIST

PUBLIC SERVICE COMMISSION FOR-HIRE DRIVER S LICENSE APPLICATION CHECKLIST MARYLAND PUBLIC SERVICE COMMISSION Transportation Division WILLIAM DONALD SCHAEFER TOWER 6 ST. PAUL STREET, 18 th Floor BALTIMORE, MD 21202-6806 TELEPHONE: 410-767-8128 OR 1-800-492-0474 FAX: 410-333-6088

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT TICE TO APPLICANTS AND EMPLOYEES Screening tests for alcohol and illegal drug use may be required before hiring and during your employment here. APPLICATION FOR EMPLOYMENT We consider applications for

More information

Recovery Housing Program Agreement

Recovery Housing Program Agreement Recovery Housing Program Agreement I have made the personal choice to live in a Recovery Residence provided by the Hancock County Alcohol, Drug Addiction, and Mental Health Services Board. I am seeking

More information

CHRISTIAN COUNTY SHERIFF S OFFICE CORRECTIONAL CENTER * CENTER 301 W. FRANKLIN STREET P. O. BOX 678 TAYLORVILLE, IL 62568

CHRISTIAN COUNTY SHERIFF S OFFICE CORRECTIONAL CENTER * CENTER 301 W. FRANKLIN STREET P. O. BOX 678 TAYLORVILLE, IL 62568 CHRISTIAN COUNTY SHERIFF S OFFICE CORRECTIONAL CENTER * 9-1-1 CENTER 301 W. FRANKLIN STREET P. O. BOX 678 TAYLORVILLE, IL 62568 SHERIFF BRUCE KETTELKAMP PHONE (217) 824-4961 CHIEF DEPUTY FAX (217) 824-4963

More information

POLICY NO Volunteer Policy (Replaces Policy Adopted 12/13/2011)

POLICY NO Volunteer Policy (Replaces Policy Adopted 12/13/2011) POLICY NO. 28-01 Volunteer Policy (Replaces Policy Adopted 12/13/2011) Policy Statement Hernando County recognizes that volunteers are essential to the productivity, efficiency and cost effectiveness of

More information

LETTER OF UNDERSTANDING

LETTER OF UNDERSTANDING LETTER OF UNDERSTANDING I am applying for a position with the Sheboygan County Sheriff s Department. I understand there are certain requirements I must meet before I can be accepted into this position.

More information

JOB SPECIFICATION APPLICATION PACKET BOOKING SPECIALIST CURRY COUNTY ADULT DETENTION CENTER

JOB SPECIFICATION APPLICATION PACKET BOOKING SPECIALIST CURRY COUNTY ADULT DETENTION CENTER JOB SPECIFICATION APPLICATION PACKET BOOKING SPECIALIST CURRY COUNTY ADULT DETENTION CENTER The attached documents must be filled out completely and returned to the Personnel Office. The office is located

More information

E. Licensed Professional Counselor A person licensed under Part 181 of the Michigan Public Health Code to engage in the practice of counseling.

E. Licensed Professional Counselor A person licensed under Part 181 of the Michigan Public Health Code to engage in the practice of counseling. MCCMH MCO Policy 9-810 DUTY TO WARN THIRD PARTIES Date: 8/05/09 B. Psychiatrist A person licensed to practice medicine or osteopathic medicine, or a person under the supervision of a psychiatrist, while

More information

** Clinical Training Requirements Checklist for Conditionally Accepted EMS Students**

** Clinical Training Requirements Checklist for Conditionally Accepted EMS Students** 1 ** Clinical Training Requirements Checklist for Conditionally Accepted 2017-18 EMS Students** The following checklist outlines required documentation for conditionally accepted 2016-17 EMS and Paramedic

More information

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A)

REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A) REQUIREMENTS TO QUALIFY AS A QUALIFIED MENTAL HEALTH PROFESSIONAL-ADULT (QMHP-A) Qualified Mental Health Professional-Adult or QMHP-A means a registered QMHP who is trained and experienced in providing

More information

POLICY NO Volunteer Policy (Replaces Policy Adopted 1/26/1998)

POLICY NO Volunteer Policy (Replaces Policy Adopted 1/26/1998) POLICY NO. 28-01 Volunteer Policy (Replaces Policy Adopted 1/26/1998) Policy Statement Hernando County recognizes that volunteers are essential to the productivity, efficiency and cost effectiveness of

More information

PATIENT INFORMATION Please Print

PATIENT INFORMATION Please Print PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred

More information

WELCOME TO VOLUNTEER SERVICE

WELCOME TO VOLUNTEER SERVICE WELCOME TO VOLUNTEER SERVICE Dear New Volunteer, It is a sincere pleasure to welcome you to the Volunteer Service of Memorial Hermann Prevention and Recovery Center (PaRC). The men and women who volunteer

More information

Return Completed Application To: ARISE & Ski, 635 James Street, Syracuse, NY 13203

Return Completed Application To: ARISE & Ski, 635 James Street, Syracuse, NY 13203 ARISE & Ski Volunteer Application We consider applicants for all positions without regard to race, religion, creed, gender, age, disability, marital or veteran status, sexual orientation or any other legally

More information

Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology

Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you

More information

Homestay Agreement Please read this thoroughly

Homestay Agreement Please read this thoroughly Homestay Agreement Please read this thoroughly To treat the Host s home as you would your own home, with respect and courtesy If you have permission to share the house with a student of the same nationality,

More information

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised February 17, 2010 Revised September 23, 2013 Revised July 1, 2016 This Notice of Privacy Practices applies to the

More information

St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101

St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101 St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101 APPLICATION FOR RENTAL A. Applicant Information DATE Catholic Charities is required to verify that all tenants of the St. Vincent Apartments

More information

Printed from the Texas Medical Association Web site.

Printed from the Texas Medical Association Web site. Printed from the Texas Medical Association Web site. Medical Power of Attorney Patient and Health Care Provider Information September 1999 General Information To be read by the Patient and Health Care

More information

EMPLOYMENT APPLICATION. Name Date Present Address Telephone ( ) Cell Phone ( )

EMPLOYMENT APPLICATION. Name Date Present Address Telephone ( ) Cell Phone ( ) COMMUNITY HEALTH PROFESSIONALS, INC. & Private Duty Services, Inc. Ada Archbold Bryan Celina Defiance Delphos Helping Hands/Lima Paulding Tri-County/Wapak Van Wert EMPLOYMENT APPLICATION Name Date Present

More information

APPLICATION FOR REINSTATEMENT OF AN EDUCATOR S LICENSE (PRINT OR TYPE ALL INFORMATION)

APPLICATION FOR REINSTATEMENT OF AN EDUCATOR S LICENSE (PRINT OR TYPE ALL INFORMATION) FORM 1R REINSTATEMENT MISSISSIPPI DEPARTMENT OF EDUCATION Office of Educator Licensure P. O. Box 771 Jackson, MS 39205-0771 TELEPHONE (601) 359-3483 OFFICE USE ONLY Application Complete / / APPLICATION

More information

St. Louis County Public Safety Innovation Fund Report

St. Louis County Public Safety Innovation Fund Report St. Louis County Public Safety Innovation Fund Report INTENSIVE PRE-TRIAL RELEASE PROGRAM Program Goal: Provide Intensive Community Supervision on Pre-Trial Defendants in lieu of incarceration at the St.

More information

The Marion County Sheriff s Office

The Marion County Sheriff s Office The Marion County Sheriff s Office Application Position: (Circle all that apply) Deputy Sheriff Dispatcher Auxiliary Deputy Other Part time Full Time MARION COUNTY SHERIFF S OFFICE EMPLOYMENT OR AUXILIARY

More information

Pierpont Community & Technical College School of Health Careers Practical Nursing Program

Pierpont Community & Technical College School of Health Careers Practical Nursing Program Pierpont Community & Technical College School of Health Careers Practical Nursing Program ADMISSION PROCESS 1. Complete and submit Pierpont Community & Technical College application including: a. Submit

More information

Dear Applicant, Upon receiving your completed application, you will be notified of your status within two weeks.

Dear Applicant, Upon receiving your completed application, you will be notified of your status within two weeks. Dear Applicant, Thank your taking the time to apply to FreedomWorks. Please follow the instructions below. Be sure to completely fill out the application and all other supportive documents. Please review

More information

SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.)

SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.) Please Fill Out Completely: St. Mary s Women s Center 1000 Cowles Clinic Way, Suite D-300 Greensboro, GA 30642 762-243-3860 phone 762-243-3879 fax Patient s Last Name First Name MI Social Security Number

More information

Southwest Florida Public Service Academy 4312 E. Michigan Ave. Ft. Myers FL Tel: (239) Fax: (239)

Southwest Florida Public Service Academy 4312 E. Michigan Ave. Ft. Myers FL Tel: (239) Fax: (239) Southwest Florida Public Service Academy 4312 E. Michigan Ave. Ft. Myers FL 33905 Tel: (239) 334-3897 Fax: (239) 334-8794 Todd Everly, Director Robert Martin III, Corrections Coordinator Jack Thomson,

More information

Name: (Last, First, Middle Initial) Home Street Address: City: State: Address: Date of Birth: In Case of Emergency Notify: Name:

Name: (Last, First, Middle Initial) Home Street Address: City: State:  Address: Date of Birth: In Case of Emergency Notify: Name: 2017-2018 PARENT/COMMUNITY MEMBER VOLUNTEER APPLICATION GETTING STARTED In order to be cleared to volunteer with Richland County School District One, you will need to follow the steps below: 1. Richland

More information

Division of Community Education Application for Certified Nursing Assistant Program CNA APPLICATION CHECK LIST

Division of Community Education Application for Certified Nursing Assistant Program CNA APPLICATION CHECK LIST CNA APPLICATION CHECK LIST Applicant Name: Phone No: Alternative No: Application Date: Please submit this information to WCCC as soon as possible. You will not be eligible to start classes if we do not

More information

Cahokia Volunteer Fire Department. Application for Membership

Cahokia Volunteer Fire Department. Application for Membership Cahokia Volunteer Fire Department Application for Membership Minimum Requirements for Membership 1) Must be a resident within the residential boundaries for at least 6 months. 2) Must be a minimum age

More information

CITY OF GLADSTONE APPLICATION FOR EMPLOYMENT (An Equal Opportunity Employer)

CITY OF GLADSTONE APPLICATION FOR EMPLOYMENT (An Equal Opportunity Employer) ~C t y i M o f i s G s l o a u d r s i t o n e ~ CITY OF GLADSTONE APPLICATION FOR EMPLOYMENT (An Equal Opportunity Employer) In keeping with our commitment to maintain a drug and alcohol-free workplace,

More information

New Jersey Motor Vehicle Commission

New Jersey Motor Vehicle Commission New Jersey STATE OF NEW JERSEY P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 ext. 5014 FAX# 609-292-4400 mvcblsprocessing@mvc.nj.gov Chris Christie Governor Kim Guadagno Lt. Governor Raymond

More information

X Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)

X Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print) In Office Policies Identification - For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card and/or driver s license at the

More information

PATIENT INFORMATION. In Case of Emergency Notification

PATIENT INFORMATION. In Case of Emergency Notification PATIENT INFORMATION Patient Name Date Nickname DOB Age Sex Race/Ethnicity Language(s) spoken at home Person completing form Relation to Patient Patient Address City State Zip Phone # Other Phone Medical

More information

ACADIA PARISH SHERIFF S OFFICE K.P.GIBSON Sheriff and Ex-Officio Tax Collector JOB APPLICATION FORM

ACADIA PARISH SHERIFF S OFFICE K.P.GIBSON Sheriff and Ex-Officio Tax Collector JOB APPLICATION FORM ACADIA PARISH SHERIFF S OFFICE K.P.GIBSON Sheriff and Ex-Officio Tax Collector JOB APPLICATION FORM Position applying for: Date of Application: Full-Time: Part-Time: Date available for work: Personal Information

More information

Outpatient Wellness Clinic

Outpatient Wellness Clinic Outpatient Wellness Clinic Patient Name: Date of Birth: Address: Phone: Email: Emergency Contact: Relationship: Phone: What is the reason for the appointment? Who were you referred by? (Physician, agency/

More information

Breakaway Teen Counselor/Staff Application **COUNSELOR FEES ARE NON-REFUNDABLE **

Breakaway Teen Counselor/Staff Application **COUNSELOR FEES ARE NON-REFUNDABLE ** Breakaway Teen Counselor/Staff Application **COUNSELOR FEES ARE NON-REFUNDABLE ** Please Mail by June 1, 2016 Counselor/Staff Administrative Fee: $35 Please contact ISM at ilsmonline.com or 217-854-4631

More information

CPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February

CPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February CPRS Application Certified Peer Recovery Specialist VCB CPRS Application Revised February 2017 - www.vacertboard.org - info@vacertboard.org 1 DIRECTIONS/CHECKLIST Documentation of high school diploma/ged

More information

APPLICATION FOR AIRPORT RESTRICTED AREA PASS ALL INFORMATION TO BE ENTERED IN BLOCK CAPITALS

APPLICATION FOR AIRPORT RESTRICTED AREA PASS ALL INFORMATION TO BE ENTERED IN BLOCK CAPITALS Page 1 of 6 Assigned RAP#: APPLICATION FOR AIRPORT RESTRICTED AREA PASS ALL INFORMATION TO BE ENTERED IN BLOCK CAPITALS TYPE OF PASS: PERMANENT TEMPORARY PROXY CARD PERSONAL INFORMATION: SURNAME: DATE

More information

Registration Form. School Name: Start Date: Grade:

Registration Form. School Name: Start Date: Grade: Registration Form Program Type: Afterschool Care Before Care School Name: Start Date: Grade: Child's Full Name: Address: City: Zip Code: Sex: Female Male Race: White Hispanic Black Other Hair Color: Eye

More information